understanding mental illness - signs... · 2015. 11. 18. · serious mental illness & crime 3...
TRANSCRIPT
Signs and Symptoms of Serious Mental Illness
Jacki Buffington-Vollum, Ph.D.
Justice Studies Department
James Madison University
Health Planning Region I
Byrne Grant Evaluation Specialist
Diagnostic and Statistical Manual (DSM) Axis I Disorders
“State” disorders
Mental disorders
Clinically significant behavioral or psychological pattern
Associated with distress, disability, or significantly increased risk of death, pain, loss of freedom
Impairment in social, educational, or occupational functioning
Examples: – Schizophrenia-spectrum
Disorders
– Mood Disorders
– Anxiety Disorders
– Substance Use Disorders
– Dissociative Disorders
– Sexual Disorders (e.g., paraphilias)
Medications are often helpful to alleviate/reduce symptoms
Schizophrenia / Psychosis
Schizophrenia / Psychosis
Primarily, disturbance of thought and
perception (and, secondarily, behavior and mood)
– Loss of touch with reality
– aka “Thought” or “Psychotic” Disorder
Examples of Disorders
– Schizophrenia, Schizoaffective Disorder
Tends to emerge in the 20’s
~1% of general population
Schizophrenia / Psychosis (cont.)
3 categories of symptoms:
– Positive Symptoms
– Negative Symptoms
– Symptoms of Disorganization
Positive Symptoms
Positive Symptoms – presence / addition of a behavior or experience that does not
occur during normal functioning
– Hallucinations: false sensory perceptions
– Delusions: false beliefs that are held
despite impossibility
Positive Symptoms: Hallucinations
Hallucinations: false sensory perceptions
Type %
Auditory 75%
Voices commenting 58%
Voices conversing 57%
Visual 49%
Tactile 20%
Olfactory & Gustatory 6%
Positive Symptoms: Delusions
Delusions: false beliefs that are held
despite impossibility
Common Delusions
– Paranoid / Persecutory Delusions – belief that
one is being plotted or discriminated against,
spied on, threatened, attacked, or victimized
Ideas / Delusions of Reference – attaching special and
personal meaning to the actions of others, or to objects
or events.
Positive Symptoms: Delusions (cont.)
Common Delusions – Delusions of Control – belief that one’s feelings,
thoughts, and/or actions are being controlled (inserted, withdrawn, broadcast) by another
– Delusions of Grandeur – belief that one is important because of significant wealth, special ability (e.g., extrasensory perception), having influential friends/job (e.g., CIA), etc.
– Religious Delusions – belief that one is a religious figure (e.g., God, the devil, has a special relationship to God, is on a mission
Positive Symptoms: Delusions (cont.)
Type % Type %
Paranoid/Persecutory 81 Grandeur 39
Delusions of Reference 49 Religious 31
Delusions of Mind Reading 48 Thought Insertion 31
Delusions of Control 46 Thought Withdrawal 27
Thought Broadcasting 23
Positive Symptoms: Delusions (cont.)
Threat/Control-Override (TCO) – belief that one is in danger (threat) and that thoughts, behaviors, feelings are being controlled by mysterious, unseen, external forces beyond their control (control override) – This combination of delusions is relatively
uncommon, BUT no solid numbers
– Some research (Link, Stueve, & Phelan, 1998) associates TCO delusions with violence
Symptoms of Disorganization
Disorganized Thought / Speech (aka “formal”
thought disorder, incoherence)
– Derailment or loose associations – slip off track
from one topic to another
– Tangentiality – answering questions in an
unrelated manner
– Speech can become so disorganized as to be
word salad
Symptoms of Disorganization (cont.)
Disorganized Behavior
– Difficulties performing even most basic
activities of daily living (ADLs – hygiene)
– Unpredictable agitation and/or flailing
– Catatonia (marked decrease in reactivity to
the environment)
Symptoms of Disorganization (cont.)
Disorganized Emotion / Affect
– Inappropriate affect
Smiling/laughing inappropriately
Crying for no apparent reason
– Unexplained irritability/hostility
Negative Symptoms
Negative Symptoms – absence or deficiency
of a behavior or experience that usually
occurs during normal functioning
– Social withdrawal or inappropriate social behavior
– Flat, blunted emotional responses
– Lack of motivation
– Lack of insight (aka anosagnosia) – inability to
recognize their symptoms even when pointed out
Detecting Psychosis
Positive Symptoms – May openly talk about them BUT typically prefer
not to
– Hallucinations: May talk to someone unseen, look around the room as if seeing or hearing someone unseen, may be distracted by internal stimuli
– Delusions: May talk openly about beliefs, behave in a manner consistent with distorted beliefs OR may only be uncovered if the focus of the delusion is touched upon
Detecting Psychosis (cont.)
Disorganized Symptoms
– At the least, hard to follow or understand
– At the most severe, incoherent
– Hardest to fake and to keep up!
Negative Symptoms
– Most likely to go undetected
NOT “squeaky wheels”
– May just seem like a quiet or unconcerned inmate
Schizophrenia Case Example
Psychiatric Treatment of Psychosis
Older, “typical” antipsychotics
– Examples: Haldol, Thorazine, Mellaril, Prolixin
– Severe side effects:
Extrapyramidal side (EPS) effects – tremors, shaking,
rigidity, drooling
In the long term, irreversible Tardive Dyskinesia –
involuntary movements (e.g., protruding tongue,
chewing, spastic limb movements, seizures)
Psychiatric Treatment of Psychosis (cont.)
Newer, “atypical” antipsychotics
– Examples: Zyprexa, Risperdal, Seroquel, Abilify,
Geodon, Clozaril, Invega
– Fewer side effects, like EPS, BUT can develop
dangerous toxic effects (agranulocytosis) AND
significant weight gain
Psychiatric Treatment of Psychosis (cont.)
In some patients, relatively severe psychosis is continuous and unrelenting – 10-25% experience no improvement with “typical,”
older antipsychotic medications
– 10% don’t respond to ANY treatment, including newer, “atypical” antipsychotic medications
– 35% respond somewhat, but NOT full remission
Poorer prognosis if left untreated
Tendency for symptoms to evolve over time
Mood Disorders
Mood Disorders
Primarily, disturbance of mood (and,
secondarily, thought and behavior)
A mood disorder exists when the individual's
mood shifts more dramatically, more
frequently, or lasts longer than “normal”
NOT just the result of situational stressors
Mood States/Episodes
Depression – characterized by persistent
sadness, finding little enjoyment in life and in
things that one previously enjoyed
Mania – characterized by extreme energy,
high and/or fluctuating mood
Mood States/Episodes
Symptoms Depression Mania
Mood Depressed mood and/or irritability
Diminished interest/pleasure in most
activities
Feelings of worthlessness, guilt
Recurrent thoughts of death
Elevated, expansive or irritable mood
Inflated self-esteem/grandiosity
Vegetative Increase or decrease in appetite
Increase or decrease in sleep
Lack of energy
Decreased need for sleep, eating
Excessive energy
Behavioral Psychomotor agitation or retardation Psychomotor agitation
Talkativeness, pressured speech
Excessive involvement in pleasurable
(and often dangerous) activities
Cognitive Diminished ability to think or
concentrate
Racing thoughts
Distractibility, diminished ability to think
or concentrate
Mood States/Episodes
Detecting Mood Disorders
Depression
– Tearfulness, sadness, hopelessness,
pessimism, miserable, “empty”
– Subdued, quiet, withdrawn behavior
– Slow speech and movement
– Lack of energy and motivation
– Like with negative symptoms of psychosis, may
just seem like a quiet inmate
Detecting Mood Disorders (cont)
Mania
– Very active – e.g., moves quickly, talks rapidly and loudly,
may not sleep for a couple of days and still is wide awake
– Active, powerful emotions – usually elevated and positive,
although often irritable – in search of an outlet
– Grandiose behavior, often inappropriate sexual
statements/behavior
– May be pleasant, funny, even charming…or annoying
– Tend to show poor judgment because feeling too good
and moving too fast to consider possible pitfalls
– Little awareness that their behavior is excessive
Detecting Mood Disorders (cont)
Severe depression or mania can involve
positive symptoms of psychosis
– Delusions
– Hallucinations
Bipolar Disorder Case Example
Serious Mental Illness and Crime
Serious Mental Illness & Crime
3 types of offenses committed by offenders
with severe and persistent mental illness
– Illegal acts that are byproducts of MI (but NOT
necessarily caused by)
“Nuisance crimes”
Violence
– Economic crimes to obtain money for subsistence
– “Mercy bookings”
Serious Mental Illness & Violence
People with serious mental illness are only
slightly more likely to commit a violent crime
than non-MI
Vast majority of violence is NOT committed
by people with MI
Vast majority of people with serious mental
illness are NOT violent
Serious Mental Illness & Violence (cont.)
Certain symptoms of psychosis are risk
factors for violence, some are protective
– Risk factors
Threat-control override symptoms
Command hallucinations
– “Protective” factors
Negative symptoms (e.g., social withdrawal)
Serious Mental Illness & Violence (cont.)
They don’t tend to target strangers
Conditions that are likely to increase the risk of violence are the same whether or not a person has MI – Individuals who felt “listened to” are half as likely
to behave violently
– Co-morbid substance abuse and personality disorder significantly increase the risk of violence among people with serious mental illness
Dual Diagnosis
aka “Co-occurring Disorders”
Comorbid mental health disorder and substance-related disorder
– Having a psychiatric disorder triples the risk of substance problems
– 39% of alcoholics and 53% of drug abuse patients had a co-existing psychiatric disorder (Regier et al., 1990)
This comorbidity skyrockets in jails/prisons – ~75% (and in some studies, up to 95%) of inmates with
serious mental illness also have a substance use disorder
Dual Diagnosis
People with MI use/abuse drugs and alcohol for a variety of reasons: – Self-medication from symptoms
– Numbing from psychosocial stressors caused by psychiatric symptoms
– Poor judgment
– High need for excitement, thrills, risks
– Addiction
– Social influences
Effects of Substance Use on Psychosis
Depressants, alcohol, opiates: Frequently used
to try to calm delusions, disordered thinking BUT
often make the person more confused,
unpredictable
Stimulants and hallucinogens: Apt to make
symptoms much worse (e.g., paranoia,
delusions, hallucinations, panic)
Effects of Substance Use on Depression
Stimulants and depressants: Can
temporarily relieve depression due to
the euphoria and sense of well-being
produced, BUT in the long run, they will
worsen depression
Hallucinogens: Often makes
depression worse
Challenges Posed by Dually Diagnosed Offenders
Teasing apart the effects of the mental illness vs. the
effects of drugs/alcohol
Interactions b/w medications and drugs of abuse
Which condition is “primary” and where should the
person receive help?
High rate of relapse of both disorders
High rate of crisis behaviors: suicide, self-injury,
overdose
Personality Disorders
EVERYONE has “personality traits” – Longstanding patterns of perceiving, relating to,
and thinking about the world and oneself that are exhibited in a wide range of social and personal contexts
It’s when they become inflexible, maladaptive, or disruptive that they constitute a Personality Disorder
Not as clearly an “illness” as mood and thought disturbance
Personality Disorders
Common Examples in Jails
– Antisocial Personality Disorder
Disregards others’ rights or safety, deceitful, impulsive,
aggressive, irresponsibility, lack of remorse
aka “psychopathy” or “sociopathy”
1-3% in general population, 50-66% in jails/prisons
– Borderline Personality Disorder
Unstable relationships, self-image, and emotion
(especially anger), impulsive, recurrent suicidal behavior
2% in general population, 12% (men)-28% (women) in jail
Suicide & Mental Illness (National Strategy for Suicide Prevention, 2007)
Lifetime risk of suicide in mood disorders is 10-15%
– Of people who commit suicide, ~60% have had some form of mood disorder
Major Depression: 2-15% die by suicide
– 30-40% of those who complete suicide had some form of major depression
– Risk of attempted suicide increased 41X in depressed patients
Bipolar Disorder: 3-20% die by suicide
Suicide & Mental Illness (National Strategy for Suicide Prevention, 2007)
Schizophrenia: 6-15% die by suicide – 20-40% will attempt suicide
Personality Disorders: 3X as likely to die by suicide (as those without them)
Substance Abuse: 40-60% of those who die by suicide are intoxicated
Comorbid depression AND another mental illness (e.g., substance abuse, anxiety, schizophrenia, bipolar) increases risk
Suicide Risk Factors (National Strategy for Suicide Prevention, 2007; HPRI Jails)
Current suicidal thoughts
– Expresses thoughts about killing self
– Has a suicide plan and/or suicide instrument in possession
Previous suicide attempts
– Has previous suicide attempt (Check wrists and note
method)
Family history of suicide
– Family member or significant other has attempted or
committed suicide (spouse, parent, sibling, close friend,
lover)
Suicide Risk Factors (National Strategy for Suicide Prevention, 2007; HPRI Jails)
History of / present mental disorders
– Has psychiatric history (psychotropic medication or
treatment)
– Shows signs of depression (crying, emotional flatness)
– Appears anxious, afraid, or angry
– Is acting and/or talking in strange manner (cannot focus
attention, hearing or seeing things not there)
Hopelessness about the future
– Expresses feeling there is nothing to look forward to in the
future (feelings of helplessness and hopelessness)
Recent discharge from hospital
Suicide Risk Factors (National Strategy for Suicide Prevention, 2007; HPRI Jails)
Substance use/abuse – Is apparently under the influence of alcohol or drugs
Stressors – Inmate’s first time in jail
– Holds position of respect in community (professional, public official) and/or alleged crime is shocking in nature.
Expresses feeling of embarrassment/shame
– Worried about major problems other than legal situation (serious illness, family illness)
– Experienced a significant loss (loss of job, relationship, death of close family member, lover) within the last 6 months
– Lacks close family and/or friends in the community